Psychotherapy for the Advanced Practice Psychiatrics (Part I Getting_Started)| NURSING 6630N GRADED A VERIFIED

I Getting Started Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse, second edition : A how-to guide for evidence-based practice. Retrieved from Created from waldenu on :33:47. Copyright © 2014. Springer Publishing Company. All rights reserved. Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse, second edition : A how-to guide for evidence-based practice. Retrieved from Created from waldenu on :33:47. Copyright © 2014. Springer Publishing Company. All rights reserved. 1 The Nurse Psychotherapist and a Framework for Practice KATHLEEN WHEELER This chapter begins with the historical context of the nurse’s role as psychotherapist and the resources and challenges inherent in nursing for the development of requisite psychotherapy skills. Using a holistic paradigm, elements of psychotherapy described include caring, connection, narrative, and anxiety management. Attention is then turned to the development of a framework for practice, beginning with a discussion of mental health and illness viewed through a cultural lens. The signifi cant role of adverse life experiences in the development, contribution, and maintenance of mental health problems and psychiatric disorders is highlighted. A hierarchy of treatment aims is introduced on which to base interventions using a stage model for psychotherapy. This framework is based on the neurophysiology of adaptive information processing and research, which posits that many mental health problems and symptoms of psychiatric disorders are due to a disturbance or dysregulation in the integration and connection of neural networks that occur in response to adverse life experiences. A case example is presented to illustrate the treatment framework proposed for psychotherapy practice. WHO DOES PSYCHOTHERAPY? The various disciplines licensed to conduct psychotherapy, depending on their respective state licensing boards, include psychiatrists, psychologists, social workers, marriage and family therapists, counselors, and advanced practice psychiatric nurses (APPNs) (Table 1.1). Educational preparation, orientation, and practice settings vary greatly among and within each discipline. In addition to basic educational requirements unique for that discipline, there are many postgraduate psychotherapy training programs that licensed mental health practitioners may pursue, such as psychoanalytic, family therapy, eye movement desensitization and reprocessing therapy (EMDR), cognitive behavioral, hypnosis, and others. Each of these training programs offers certifi cation and requires some length of training: approximately 1 year for EMDR therapy (i.e., 40 academic didactic and 10 consultation hours for basic Levels I and II training; plus, in order to obtain certifi cation an additional 20 consultation hours, 12 continuing educational units, 2 years’ experience with a license in mental health practice, and a minimum of 50 sessions with 25 patients) and 4 to 5 years for psychoanalytic training (i.e., 4 years of coursework and supervision, ongoing practice, and one’s own experience in psychoanalysis). Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse, second edition : A how-to guide for evidence-based practice. Retrieved from Created from waldenu on :33:47. Copyright © 2014. Springer Publishing Company. All rights reserved. 4 I GETTING STARTED TABLE 1.1 Basic Education, Orientation, and Setting of Psychotherapy Practitioners Discipline Education Orientation/Setting Psychiatrist MD (medical doctor) or DO (Doctor of Osteopathy); 3-year psychiatric residency after medical school Biological treatment, acute care, psychopharmacology and specifi c psychotherapy competencies for psychiatric MD residents; often inpatient orientation Psychologist PhD (research doctorate in psychology) or PsyD (clinical doctorate in psychology); both usually 1-year internship after doctorate Psychotherapy and psychological testing Master’s level psychologist MA (Master of Arts) or MS ( Master of Science) or MEd (Master of Education) Psychotherapy: some modalities, psychological testing Social worker MSW (Master of Social Work) Psychotherapy: interpersonal, family, group; community orientation Marriage and family therapists MA (Master of Arts) Systems and family therapy, marriage counseling; community outpatient orientation Counselor MA (Master of Arts in counseling) or MEd (Master of Education in counseling) Counseling, vocational, and educational testing; outpatient orientation Advanced practice psychiatric nurse (APPN) (clinical specialist in psychiatric nursing or psychiatric-mental health nurse practitioner) MSN (Master of Science in Nursing) or DNP (Doctor of Nursing Practice) Psychopharmacology and psychotherapy; group and individual, sometimes family Postgraduate training and ongoing supervision are encouraged for APPNs who wish to gain profi ciency and deepen their knowledge in a particular modality of psychotherapy. Because it is highly unlikely that any one method will work for all problems for all people, the APPN who has additional skills such as hypnosis, EMDR therapy, family therapy, imagery, or ego state work will be more likely to help those who seek help. There are many ways to help the diverse number of patient problems and patients who seek our help, and beware of therapists who believe that ”one size fi ts all”; in other words, if the only tool you have is a hammer, you are likely to treat every problem you encounter as a nail. In 2002, the American Psychiatric Review Committee mandated that all psychiatric residency programs require competency training in psychodynamic therapy (PDP), cognitive behavioral therapy (CBT), supportive and brief psychotherapies, and in psychotherapy combined with psychopharmacology in order to meet accreditation standards (Plakun, Sudak, & Goldberg, 2009). This list was further refi ned to what is termed the Y Model, with the stem of the Y being the shared elements or common factors in psychotherapy while the arms are PDP and CBT with supportive therapy at the base of the Y (Plakun, Sudak, & Goldberg, 2009). Delineation of these competencies is important in that it is a direct response to the increasing emphasis on medication as the treatment for psychiatric disorders and reaffi rms the importance of psychotherapy in psychiatric treatment. These core competencies in medical education indicate a signifi cant cultural shift that may also herald academic changes for advanced practice psychiatric nursing education. Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse, second edition : A how-to guide for evidence-based practice. Retrieved from Created from waldenu on :33:47. Copyright © 2014. Springer Publishing Company. All rights reserved. 1 THE NURSE PSYCHOTHERAPIST AND A FRAMEWORK FOR PRACTICE 5 Many factors in graduate psychiatric nursing education challenge APPNs in attaining competency in psychotherapy. One challenge for nursing education is how to teach the requisite competencies and essentials that are required in graduate nursing curricula without increasing the total credit load. To remain competitive, programs need to offer coursework that can be completed in a reasonable amount of time and with a reasonable number of credits. It is not possible in a short period—usually 2 years for most full-time graduate master’s degree nursing programs and 3 years or more for the Doctorate of Nursing Practice (DNP) degree, to attain profi ciency in psychotherapy, but competency must be achieved. Psychotherapy competency was identifi ed as necessary for all psychiatric-mental health nurse practitioner (PMHNP) programs as of 2003 (National Panel, 2003) and reaffi rmed with the 2013 revised PMHNP Competencies (NONPF, 2013). With these competencies delineated and endorsed by the Commission on Collegiate Nursing Education (CCNE) for accreditation, all graduate APPN programs seeking CCNE accreditation must teach psychotherapy skills. Another change in nursing education that will signifi cantly impact APPNs is the endorsement of the DNP by leaders in nursing, the National Organization of Nurse Practitioner Faculty (NONPF), and the American Association of Colleges of Nursing (AACN). The DNP degree is envisioned as a terminal practice degree and is proposed to supplant the Master of Science in Nursing (MSN) degree for nurse practitioners by 2015 and will include a clinical research focus. Impetus for this shift came from the lack of parity with other health care disciplines, the high amount of credits required in current master’s curricula, current and projected shortage of faculty, and the increasing complexity of the health care system (Dracup et al., 2005). Debate continues about whether this terminal practice doctorate will enhance or dilute advanced practice. It is not clear how curricula and program requirements will evolve to provide the needed practice expertise for APPN students. Faculty need current expertise in psychiatric advanced practice to effectively teach, and concerns have been expressed about whether graduate faculty have greater academic experience than practice experience because academia traditionally rewards faculty who publish and do research. Clinical practice and teaching are often overlooked in promotion decisions, and faculty members tend to emphasize research over practice, which may not bode well for APPN faculty expertise in psychotherapy skills. A survey in 2009 revealed that most APPN practice time is spent prescribing, conducting diagnostic assessments, and psychotherapy with medication management but rarely solely conducting individual psychotherapy (Drew & Delaney, 2009). A signifi - cant challenge for graduate nursing education is the diffi culty of fi nding preceptors and clinical sites for psychiatric graduate nursing students to practice psychotherapy. Most settings have social workers who conduct psychotherapy while the APPNs most often prescribe. This is a cost-effective approach for the agency or clinic because APPNs usually earn more per hour than social workers, but it does not provide the student nurse psychotherapist with adequate experience to practice psychotherapy. APPN students can sometimes work out an arrangement in which the student can see the preceptor’s patients for psychotherapy while the psychiatric APPN preceptor manages the medication. In addition to the liability issues with this arrangement, space constraints, agency policy, or lack of adequate psychotherapy supervision may prohibit the student from seeing an adequate caseload of patients for psychotherapy. A national survey of 120 academic psychiatric-mental health nursing graduate programs confi rmed the scarcity of sites and found a wide range of individual psychotherapy practice hours required for students, ranging from a minimum of 50 to a maximum 440 hours in the programs for which a certain number of requisite hours are required for psychotherapy (Wheeler & Delaney, 2005). For approximately 50% of programs, however, no designated number of psychotherapy practice hours was required, and medication management hours were integrated along with psychotherapy. Consequently, most Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse, second edition : A how-to guide for evidence-based practice. Retrieved from Created from waldenu on :33:47. Copyright © 2014. Springer Publishing Company. All rights reserved. 6 I GETTING STARTED graduate psychiatric nurses leave graduate studies with a less than adequate knowledge base in this area, and often do not feel competent to practice psychotherapy. Faculty teaching students in graduate programs, when asked whether their students had achieved competency on graduation felt decidedly mixed with some stating that they did not envision a future role as psychotherapist and others suggesting further training and supervision for competency to be achieved. Working with people in the intimacy of psychotherapy is an honor, and much good can be done, as well as a great deal of harm. At vulnerable times in their lives, people see the psychotherapist as an expert, and this role often is imbued with a great deal of power and credibility. This privilege also comes with an ethical responsibility for the nurse psychotherapist to get as much training, supervision, and experience as possible in graduate studies and throughout her or his professional life. Expertise is a lifelong pursuit, and continuing education is imperative for those who wish to practice competently. Most licensed mental health professionals in other disciplines, which have considerably more psychotherapy practice in their programs than graduate psychiatric nursing programs, agree that it takes at least 10 years to become a skilled psychotherapist. Stages of Learning Benner offers a model (1984) of role acquisition from novice to expert that examines the levels of competency for the novice nurse psychotherapist. It is likely that the graduate student who is pursuing a master’s degree or postmaster’s certifi cate as an APPN has practiced as an expert in an area of specialization before graduate studies. To transition from expert back to novice is often a painful and anxiety-provoking process. The beginning nurse psychotherapist has most likely interacted professionally with many different types of patients, but there is usually much anxiety about the fi rst session in the role as psychotherapist. There is usually no one right thing to say. In psychotherapy, there is much ambiguity and often no right answers. Juxtaposed to Benner’s Model is the Four Stages of Learning Model, which may help to allay anxiety for those who are beginning to learn psychotherapy (Table 1.2). Although there is some controversy regarding who developed this model, it is thought that learning takes place in four stages: 1. Unconscious incompetence (i.e., we do not know what we do not know) 2. Conscious incompetence (i.e., we feel uncomfortable about what we do not know) 3. Conscious competence (i.e., we begin to acquire the skill and concentrate on what we are doing) 4. Unconscious competence (i.e., we blend the skills together, and they become habits, allowing use without struggling with the components) The challenge initially for novices is that they are becoming increasingly aware of being incompetent as progress is made. This is likely to generate anxiety. Unique Qualities of Nurse Psychotherapists The history of the one-to-one nurse–patient relationship and nurses conducting psychotherapy is detailed by Lego (1999) and Beeber (1995). Table 1.3 highlights the important events. The late 1940s were marked by the development of eight programs for the advanced preparation of nurses who cared for psychiatric patients. An extremely important debate took place over the next few decades about the nurse’s role as Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse, second edition : A how-to guide for evidence-based practice. Retrieved from Created from waldenu on :33:47. Copyright © 2014. Springer Publishing Company. All rights reserved. 1 THE NURSE PSYCHOTHERAPIST AND A FRAMEWORK FOR PRACTICE 7 psychotherapist. This culminated in the 1967 American Nurses Association Position Paper on Psychiatric Nursing, which clarifi ed the role of the clinical specialist in psychiatric nursing as psychotherapist, and certifi cation for the specialty began in 1979. In the 1990s PMHNP programs were developed, and this culminated in the PMHNP competencies that included psychotherapy as an essential competency required for all PMHNPs (Wheeler & Haber, 2004). The APPN role of psychotherapist has solid historical roots from the inception of advanced practice psychiatric-mental health nursing, whereas the prescribing role is a much more recent step in the evolution of the specialty (Bailey, 1999). After the issue of whether nurses should do psychotherapy was resolved, the literature examined the unique qualities that nurses might possess as psychotherapists compared with those in other disciplines who practice psychotherapy. Several strengths were cited: nurses’ ability to be patient because they have worked with the chronically ill and have respect for others’ limitations; nurses are realistic and possess excellent observational skills, resourcefulness, innovation, and creativity (Smoyak, 1990); nurses’ view TABLE 1.2 Comparison of Benner’s Model and the Stages of Learning Stages of Learning Benner’s Model Unconscious incompetency Novice no experience, governed by rules and regulations Conscious incompetency Advanced beginner recognizes aspects of situations and makes judgments Conscious competency Competency/Profi ciency 2 to 5 years experience, coordinates complex care and sees situations as wholes, and long-term solutions Unconscious competency Expert fl exible, effi cient, and uses intuition TABLE 1.3 Timeline of the History of the Nurse Psychotherapist